RED ALERT

You'll probably never hear about it, but blushing can ruin people's lives - And while many consider it a psychological problem, there is a controversial surgical solution. John Van tiggelen reports.

Before her operation, Sonya Coulsen* was incapable of marrying her boyfriend of six years. She loved him and he was keen, but she nursed a secret. Nobody knew; not her mum, not her best friend, not even her sister. Had she told them, they might not have believed it. Yet it controlled her, crippled her, as few secrets can. What she'd tried to keep hidden from the world, but what had kept her hidden instead, was a fear of blushing.

Everyone blushes, including dark-skinned people. We blush when we experience shame, or embarrassment, even praise. It's an emotional response as regular as smiling. But for a very silent minority, barely acknowledged in psychology, let alone in medicine, the blushing is excessive. As common in men as women, and affecting as many as one in 40 people, pathological blushing impairs the ability to work, to relate and to love. Sufferers experience the blush like a mini panic attack; it consumes them and shuts down rational thought.

Essentially, they blush because they're terrified that they will. It's always on their mind. Once they've turned red in front of a particular person, or in a particular situation, they're cued to do so again, and so all human contact becomes a minefield of potential triggers. Sufferers feel safe with no one and go to great lengths to avoid any sort of attention. They tend to melt into the background or flit in the foreground, or just run.

Sonya flitted and ran. She took a gap year to travel, went interstate to study and managed to get through her early 20s by choosing jobs that combined routine with set-pieces, as a waitress and as a flight attendant. (As a flight attendant, she strenuously avoided performing the safety routine, instead sticking to the voice-overs.)

But her degree was in commerce. She longed to progress in her field. Each time she landed a new job, she'd think, "This is it, a clean slate." She'd cake on foundation, deepen her tan, wear a scarf, style her hair over her face. But within six months, each new workplace became as webbed with cues as the last - the coffee station, the lunchroom, the weekly meetings, attractive colleagues. "I just went from job to job, hoping it would go away, but it never did."

It also ruled her personal life. In her teens and early 20s, she'd drown her fear of blushing by downing four or five drinks before going out. She'd pick the restaurant and turn up early, so she could choose where to sit (always in a corner). Sometimes she wouldn't turn up at all - friends and family became inured to last-minute excuses. As dinner parties became the norm, she'd control the lighting and busy herself cooking and serving and clearing plates. Whenever the conversation threatened to turn to her, she'd get up to fetch something or go to the toilet.

"I was forever on high alert. So much time and effort went into planning the fine detail of everything," says Sonya. "Everything I did or said was thought through: how will this affect the risk of me blushing? I'd start blushing because I'd be so worried that I'd blush, and then I'd keep blushing because I was so embarrassed about blushing in the first place. It was a nightmare."

no one knows why humans blush. it serves no obvious purpose. Sigmund Freud thought blushing was a manifestation of shame, emanating from repressed sexual arousal. Charles Darwin contended the prospect of humiliation made people blush, which he described as that "most peculiar and the most human of all expressions". Either way, researchers remain mystified about the evolutionary benefit of self-consciousness expressing itself in a way that actually intensifies it. Perhaps the reddening signals helplessness (Please Save Me!) or a warning (Wrong Way, Go Back). Others theorise it serves to cool the blood through the skin, in order to restore calm to the mind.

At least we know how we blush. Blushing is part of the "fight, fright or flight" response, which is activated through the sympathetic nervous system. As soon as someone feels vulnerable, the sympathetic nervous system switches the body on to high alert, ready for action. The heart pumps faster, muscles tense, the gut shuts down and the blood vessels in the face, ears and neck dilate with blood.

Research has shown this flush of blood is no greater in people who blush excessively. They just feel it more and blush more often. Psychologists, in so far as they think it is a problem at all,

regard excessive blushing as a social phobia, one that can be cured by therapy. The blushing is a symptom of an underlying anxiety, nothing more.

In the past 15 years, however, medicine has stealthily moved to pin the blame on the messenger. The International Society of Sympathetic Surgery, a body founded 10 years ago by surgeons performing "sympathectomies", or operations disabling the sympathetic nerve chain, asserts the nerves are "overactive". Thus the surest cure for excessive blushing is surgery, not therapy.

"I regard it as an illness. It's a dysfunction of the autonomic nervous system," says Dr Roger Bell, a Melbourne vascular surgeon who specialises in the procedure. "In everyone subjected to stress there will be a sympathetic response, but for some people the threshold appears very low. Their sympathetic nervous system is stimulated with very little provocation and once it's triggered, it's easier to trigger it again. That's what I think happens.

"A lot of people who come to see me say they are not anxious people, but this is making them anxious. Their GP will say, 'What are you worried about? Everyone blushes.' But when I ask, 'How does this actually affect you?' three-quarters of the people who come to see me start crying. The consequences are catastrophic, because it affects their socialisation. I've treated people who have become alcoholics to overcome their blushing. It actually ruins their lives."

The condition most closely related to severe blushing is excessive sweating of the face and hands, known as hyperhidrosis. It, too, is mediated by the sympathetic nervous system. It was the surgical treatment of hyperhidrosis in the early 1990s that led Scandinavian surgeons to observe it also happened to stop blushing.

"You can have both conditions, but generally you're troubled by one or the other," says Bell, who has been performing sympathectomies for 15 years, ever since keyhole surgery removed the need to slice open the chest.

Yet the procedure remains highly contentious. The sympathetic nervous system helps regulate body temperature as well as heart rate and breathing, and intervention is risky. Several leading hospitals in Europe no longer offer it, and the procedure is increasingly prone to litigation in the US.

Two years ago, a review by the Australian Safety and Efficacy Register of New Interventional Procedures concluded that "a lack of high-quality randomised trial evidence [on sympathectomies] means that it is difficult to make a judgment on the safety and effectiveness of this technique". Although many tens of thousands of procedures have been performed around the world, un-biased, long-term follow-up studies simply do not exist. All that can be said is that between one and 40 per cent of patients are dissatisfied within months of the operation, depending on which surgeon's figures you believe. (Bell claims it's about 10 per cent in his practice.)

Usually the dissatisfaction stems from an unpleasant side effect. All patients who can no longer sweat on their upper bodies can expect some level of "rebound" or "compensatory" sweating on their lower half: the groin, the buttocks, the lower back and the feet. For some - one in five is the ballpark figure, especially once patients have endured a summer - this perspiration is severe, and may be no less mortifying than the original propensity to blush.

Bell, the country's most practised sympathetic surgeon, claims no more than one in 50 of his patients rue the operation because of rebound sweating, though without routine follow-up beyond one week post-op, the figure is hardly definitive. He also asserts that with experience he has become better at predicting which patients are more likely to get it (uptight, overweight men).

"I tell patients that if blushing is a problem they can live with, don't take the risk [of rebound sweating]. But if it's paralysing your life, then it might well be worth doing. A lot of patients are so desperate, they don't care about the side effects."

About a dozen surgeons in Australia operate for blushing, but their methods vary greatly. Some disable the nerves by cutting them, others by clamping them and still others by injecting Botox. Bell "ablates" the nerves by cauterising or burning them. "There are almost as many different ways of doing it as there are surgeons," he says. "The way I do it is the more popular way of doing it. I find it safe, and I think my results are as good if not better than everyone else's."

Bell fell into his specialty almost by accident. "For years I knew there was a big need out there and that if someone just marketed this, you'd make a killing. People with facial blushing or sweaty hands suffer in silence. They hide it and their GPs don't generally know anything about it.

"But I didn't have an entrepreneurial streak in me. Then a couple of years ago I became friendly with a plastic surgeon and he said, 'Why don't you set up a website?' So I did. One of the first guys who came to see me was from [Melbourne's] Fox FM and he said, 'Why don't you put ads on the radio?' I did, and things just took off. Until two years ago I was doing about five or 10 sympathectomies a year. Now I'm doing well over 100 a year, maybe 150."

Bell's practice manager refers me to half a dozen satisfied clients. Yet the internet teems with cautionary accounts of unforeseen consequences. Over several weeks, I track down five aggrieved Australians via online forums. (None of them was Bell's client.) Two of them had sought out the procedure after seeing it promoted on a TV program. All five endure profuse rebound sweating below the nipple line, as predicted, but a no-less-debilitating side effect in three cases is bradycardia, or a low heart rate. One says she's become prone to fainting spells. Another, a long-distance runner, says the operation has cost him both speed and stamina.

A sympathectomy is known to cause a modest drop in heart rate, yet surgeons don't always raise this during initial consultations, because most patients are unlikely to notice it post-op. But some are more affected than others, and typically complain of their heart rate being slow to respond when there's a demand for physical - or mental - exertion. A sympathectomy may potentially affect lung performance, too. Add the body's reduced capacity to cool itself, and it's little wonder physical performance may be compromised. All of the above five have lost their jobs and are on anti-depressants. None wishes to be identified.

The only name I'm free to use is that of Tim McCarty, a Sydney electrician. McCarty had his sympathetic chain clamped for blushing in 1999. The advantage of clamping the nerve with titanium clips is that, theoretically at least, the procedure is reversible. Alarmed by the side effects, McCarty arranged to have the clips removed within two weeks. It did no good. McCarty went on to found an online victims' support forum, where he wrote of feeling "like a car with a damaged radiator, and without a thermostat". In 2007, he took his own life.

Surgeons tend to dismiss these stories as "hysterical". Unhappy people will always outnumber happy ones online, and anxious people who undergo surgery for blushing may well be prone to blaming the surgeon when they find their anxiety/unhappiness resumes unabated. Yet surgeons cannot have it both ways - they're the ones claiming excessive blushing and sweating are not caused by anxiety, per se, but by a nervous system that has gone rogue and needs to be taken out.

The unusual case of Ally, a 38-year-old nurse, helps unpick the conjecture. Ally was among the first Australians to have a keyhole sympathectomy for stress-related sweating. Then 22, she chose to have her sympathetic nerves disabled on just one side, initially, "to see how it went". Sure enough, her right hand stopped sweating, so that she was at last able to shake hands. This left her less anxious, so that her left hand improved, too. Unhappily, it also meant that each time she got physical, half her face would be pasty and dry, the other half ruby-red and dripping. "I was a freak," she says. "Still am. I wish I'd waited till I'd grown up. Three months after the operation I got pregnant, which helped me get over my insecurities more than surgery ever could. There's nothing like having a child to make you realise you're not the centre of your own universe."

Sonya coulsen can still recall the weather, the street and the clothes she was wearing when she first heard Dr Roger Bell's Do-You-Suffer-From-Blushing? advertisement on the car radio. "I went bright red, even though I was by myself. It was like there was nowhere to hide any more."

She went to see Bell in his grandly appointed rooms, and broke down within minutes. "Talking to Roger, I realised for the first time it wasn't something in my head. I had some kind of short-circuit in me, like I was wired to blush, and I didn't have to live with this weakness. I could do something about it, after all. "

Bell explained the medical risks. The operation would cost her upwards of $5000. But she'd already made up her mind. "I'd have shelled out $50,000. What's a life worth living worth?"

Three weeks later, the night before the operation, she lay in bed with her boyfriend. She had yet to tell him anything. The surgery required an overnight stay in hospital and would leave four tiny scars, two below each armpit. It was near midnight when she finally brought up her operation.

"He was like, 'Hang on. You're WHAT?!'" She blurted it all out then: her dread of blushing, the lengths she'd gone to to hide it from him. She even confessed to some of the social engagements she'd sabotaged. "I just bawled and bawled and bawled. He had no idea."

They went online to do some last-minute Googling. Sonya had glossed over some of it before, but this time the Don't-Do-It information pages and various forums for people regretting their surgery alarmed her. Maybe it was too risky. Maybe opening up to her boyfriend had been cathartic. Maybe therapy was her best bet. She rang the clinic hours later to cancel. "I was a total mess."

The blushing did not let up, though. She saw a psychiatrist and was only able to tell him about her phobia by turning her chair to face the wall. The psychiatrist prescribed anti-depressants, but she wasn't depressed. She changed jobs, again. She quit drinking coffee, took a holiday, drank herbal remedies and tried confronting her phobia by asking workmates out to lunch. A psychologist told her to focus on her breathing. Next he prescribed "mindfulness" therapy to concentrate her thinking. He also probed her childhood.

Sonya was convinced her fear of blushing had something to do with her fear of failure as a child. She'd been "a bitch of a kid, terribly driven". "I was a perfectionist. It wasn't my parents' fault; my sister was the opposite." Sonya piled pressure on herself at school until, at 16, she ran into chronic fatigue syndrome. "That taught me to chill out, but then the blushing started. It was weird. I felt like I was turning into two different people, one strong, one weak, and I was losing control over which one I was."

But her therapist wanted more. Surely there was some childhood trauma she was repressing? Some abuse, perhaps?

"That's when the penny dropped," Sonya says. "I was almost 30. Therapy didn't have the answers and I wasn't going to grow out of it. I walked out of there and rang Dr Bell's rooms."

Though the majority come to him in their 20s and 30s, Roger Bell has treated people well into middle age for excessive blushing. "One woman was in her mid- to late 40s. She'd never been on a date. She had a great result, and her life changed, but you can't help but think what a different course her life might have taken if she'd had that operation when she was 18."

Bell has, in fact, performed sympathectomies on blushing teenagers. It's an aspect that disturbs psychologists. Catherine Madigan, who runs a practice called Shyness and Social Anxiety Treatment Australia, points out that most teens who blush profusely either grow out of it or learn to deal with it, as she herself did years ago. For this reason, the procedure is banned for patients under 20 in countries such as Taiwan, where surgeons perform more sympathectomies per head of population than anywhere else. (Excessive sweating, with or without blushing, is more prevalent in south-east Asians, possibly for genetic reasons.)

"The average age of the people I see for social phobia is about 30," explains Madigan. "That's when people get serious about life, when something like excessive blushing can really hold you back, professionally and socially."

Unlike some psychologists, Madigan acknowledges the operation has a place as a last-resort option, possibly even for teens. "You'd only do it if you were absolutely desperate. I know of boys who resorted to wearing foundation to school." But she maintains surgery treats only the symptom. "Some people are just more sensitive by nature. They have a genetic predisposition to anxiety. But the operation is not a cure. People will still be anxious. It's like gastric-banding surgery: it makes you thin, but it doesn't solve why you were eating so much in the first place.

"The thing to get into people's heads is that no one gives a toss if you blush. All our problems are massive to us, but then we're so self-absorbed."

Madigan puts me in touch with two people with experience of sympathectomies - one negative, one positive. The former, a script writer, is devastated. She had it done in Sydney four years ago, at 36. Her heart rate dropped to the point she claims she lost vigour and focus, at the cost of her career. She's presently suing the surgeon. But in a way, the experience of the second client, a 31-year-old human-rights lawyer, is no less alarming. Before his operation for blushing, in 2010, he could hardly address a judge, or a girl, or string five days of work together. "Now I'm on four committees, my boss loves me and when it comes to women I can't help myself - last month I [bedded] five in one week.

"I feel like I'm playing catch-up," he says, his face pale as ice. "It really gives you an edge, to know you have the ability to go into a meeting, or into a courtroom, and physically not get rattled. I'm the coolest person in the room. Even my personal trainer can't work out why my face doesn't work up a sweat."

Although he continues to see Madigan to deal with "residual anxiety issues", he insists he feels "cured". "It's not like I'm seeking treatment," he says. "More like perfecting the model."

It's not unusual to hear people who have undergone sympathectomies describe themselves as feeling emotionally "colder" than before. Among psychologists and neurologists alike there is concern, but no evidence, that the procedure limits alertness and arousal as well as fear, and might affect memory, empathy and mental performance. Professor Ronald Rapee, the director of the Centre of Emotional Health at Sydney's Macquarie University, says he's counselled several people who complain of feeling "robot-like" in the long-term wake of the operation. "They're happy they no longer blush, but they miss the highs and lows they used to feel."

Rapee's centre runs 12-week therapy courses for social phobics, including people with blushing phobia. He says 50 per cent of clients leave feeling better, another 40 per cent experience some improvement and about 10 per cent don't appear to benefit.

"The core of the problem is what other people think of you," he says. "Blushing phobics have a distorted perception of how obviously they blush, and how other people respond to it. That's where therapy comes in: you can't eliminate blushing, but you can decrease the fear of blushing by showing it doesn't hurt you." (Still, to name another example, impotence is typically cast as a psychological problem, too, but that hasn't stopped medicine from coming up with the answers.)

According to Chris Hensman, who runs the Australian Centre for Hydrosis and Facial Blushing, a new clinic in Melbourne's far eastern suburbs, the surgical solution is presently "the best fit" for excessive blushing.

"There is an underlying physical component. These nerves are overactive and we can reduce this overactivity with surgery."

Hensman, who performs about two sympathectomies a month - his main line of business is gastric banding - claims the procedure "improves quality of life in 60 to 80 per cent of patients". But Hensman, who uses the clamping technique, is evasive about what proportion of patients request the clips to be removed and, if so, whether the nerves actually regain function. There is as yet no peer-reviewed data demonstrating the reversibility of the clamping technique, adding to psychologists' concerns that blushing surgery is market-driven, rather than evidence-based.

"Not everything in medicine is explained," says Hensman, in defence of colleagues being increasingly targeted by lawyers. "All surgeons are scientists, they have this dual life. They look after patients, but constantly seek to improve. The best surgeons are pioneers, but if you're a pioneer, you're going to be in someone's gunsights. We can't wait for all the pieces of the jigsaw to fit."

As sonya is wheeled into theatre, the old fear flares in her eyes one final time. She is blushing so fiercely that, even after the anaesthetist has put her to sleep, it takes minutes for the redness to recede.

The theatre assistants manoeuvre Sonya into position. Her right arm is strapped to a beam above her head, her left arm out wide, with her face and body rolled towards it, like an archer laid flat.

The trickiest part of the operation is collapsing each lung in turn, to allow access to the nerve trunks inside the chest wall. To this end, the anaesthetist inserts a double-barrelled tube down Sonya's windpipe, so that he may independently deflate and inflate each lung.

Bell makes two tiny incisions, each less than a centimetre long, below Sonya's right armpit. Into one he inserts a "port" for the pea-sized video camera and through the other he threads the diathermy probe. On an overhead screen, the pink lung falls away to expose the inside of the chest wall, along with Sonya's beating heart. Bell quickly homes in on the glossy sympathetic chain running lengthways along the spine. As it crosses the ribs, it bulges a little. These nodes, or ganglia, comprise the nerve cell bodies. "That's the safest place to attack the chain because there are no blood vessels there," explains Bell. "I ablate it at the level of the second and third ribs. If you want to cure someone who's got excessive sweating in the armpits, you go down a little bit lower, and take out the fourth as well. Unfortunately it doesn't always work; in some people you don't dry the armpits. Sometimes the nerve supply comes from even lower."

With the diathermy probe, Bell burns two circles, each the size of a five-cent piece. He burns a third circle out wider on the second rib, to knock out the unfortunately named nerve of Kuntz. No one actually knows what function this nerve serves, if any, but Bell likes to take it out for good measure, in case some facial fibres are routed through it. "The nerve of Kuntz can't always be identified, but if it can be, and you don't ablate it, you may not get a good result," he explains.

Using the video camera, Bell snaps a photo of his handiwork before repairing the incisions with just a stitch each, once the lung is safely reinflated. Then Sonya is repositioned for the process to be repeated on her left side.

When she wakes up an hour or so later, the first thing she notices, apart from a slight pain in her chest, is how dry her hands are. From now on she'll have to lick her fingers to turn a page. (Another of Bell's clients, an elite footballer, now wears gloves to mark a ball.) But it's not until her boyfriend raises the subject of blushing in the car on the way home, a sure-fire cue in the past, that she finds she stays cool. "I waited for that sinking feeling, for myself to seize up, but I found I just kept breathing normally," says Sonya. "That's when I knew it had worked."

three weeks later, over lunch in a busy cafe, a beaming Sonya tells me she has almost taken her newfound confidence for granted. "A month ago I could not have met you like this," she says. "But you know, about four days after the operation, I'd almost forgotten what I was like. I just felt normal, whole, like I was back in my own skin."

As she talks she shifts around in her seat, or adjusts her cotton dress. She can't help but sweat now, even on cool days. "It's like living in the tropics with your bottom half, and in the clouds with your top half," she says. "It's okay. I just change my socks twice a day and wear liners in my shoes."

She says she looks back on her blushing 20s as the lost years, but she's far from bitter. "It's formed me as I am. The way I was as a kid, so driven, I'm glad I'm not that person. My experience has held me back, but it has also humbled me, and taught me what it feels like to be vulnerable. That's not a bad thing."